“Shock tactics”, ethics, and fear. An academic and personal perspective on the case against ECT

Summary Despite extensive evidence for its effectiveness, ECT remains the subject of fierce opposition from those contesting its benefits and claiming extreme harms. Alongside some reflections on my experiences of this treatment, I examine the case against ECT, and find that it appears to rest primarily on unsubstantiated claims about major ethical violations, rather than clinical factors such as effectiveness and risk.


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A recent review discussing the efficacy and safety of modern electroconvulsive therapy (ECT) finds 19 that it is still the "most effective treatment for severe, psychotic or treatment-resistant depression" (1). 20 While ECT is viewed by many clinicians and recipients as indispensable in treating debilitating and 21 "life-threatening" severe mental illness (2,3), it nevertheless remains, arguably, the most stigmatised, 22 misunderstood, contested, and feared psychiatric or perhaps even medical, treatment. A few days after 23 publication of the review, a short and sensationalist newspaper article, "Shock Tactics" (4), directed 24 anyone "considering having a big electric shock passed through your brain" towards a Psychology 25 Today article by an influential academic ECT-opponent, disputing efficacy and calling for urgent review 26 of a treatment with "risks of brain damage and death" (5). As a researcher focusing on medical ethics 27 and law, but also someone with considerable lived experience of receiving ECT, my aim here is to 28 examine the nature and validity of the extreme and often vitriolic opposition to this treatment.

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Probably the strongest feeling engendered by the notion of ECT is fear. ECT involves an electrical 30 charge being passed through the brain to induce a seizure and cause a radical shift of mental state. 31 Perhaps unsurprisingly, this description itself might sound alien, scientistic, and frightening. Added to 32 this are multiple cultural and media representations situating ECT firmly within the 'dark side' of 33 psychiatry (6,7). Most well-known is the iconic 1975 film, One Flew Over the Cuckoo's Nest, 34 portraying psychiatry as a misused tool of repressive social control. Jack Nicholson's character, who is 35 not mentally unwell, forcibly receives ECT, without anaesthetic, as punishment for insubordinate 36 behaviour. The effects of this treatment can become easily conflated with the gruelling final scene 37 showing Nicholson's near-vegetative state, resulting from a psycho-surgical procedure not shown and 38 no longer practised. The takeaway impression of ECT is as a sadistic and illegitimate process, punitive 39 rather than therapeutic, and capable of, effectively, destroying the brain. No famous depictions of ECT 40 within contemporary psychiatric practice exist to counter these images, demonstrating the severity of 41 the conditions it treats and its potential benefits. No wonder that ECT remains an object of fear. Yet, 42 for myself, as for many others for whom ECT has been a life-saving treatment, the greatest fear 43 surrounding ECT is that it might one day be inaccessible or abolished.

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A 2020 review by prominent ECT critics concludes "There is no evidence that ECT is effective for… 71 its target diagnostic group-severely depressed people, or for suicidal people, people who have 72 unsuccessfully tried other treatments first, involuntary patients, or children and adolescents" (8). Such 73 claims, common within anti-ECT literature (9,10), seem strange and are easily challenged, given 74 considerable evidence and abundant patient and clinical testimonies to major benefits (1,3,11-15), 75 including many calling for ECT's use not to be restricted to 'last resort' treatment (1,3,11,12,15). 76 Research on ECT's effectiveness is too extensive to summarise or assess here. The critical 2020 review 77 only considered studies between 1956 and 1985, with many of its findings highly disputable, 78 particularly in a modern context (15). These points aside, however, let us consider the broader 79 implications of this anti-ECT viewpoint.

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The first question must surely be motivation. Around 1.4 million people worldwide receive ECT 81 annually (1). In psychiatric terms, ECT is relatively costly and complex, in most countries involving 82 general anaesthesia, with estimates of annual treatment costs which "can exceed $10 000" (14). If, after 83 80 years of ECT, there really was no evidence for effectiveness, why would healthcare providers 84 continue funding ECT and what would psychiatrists stand to gain, especially in the face of such 85 acrimonious criticism?

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Moreover, claiming that psychiatry knowingly inflicts an invasive medical treatment with potentially 87 serious side effects and no evidence of substantive therapeutic benefits implies a global breach of core 88 medical ethical principles. Not only would this violate both beneficence and nonmaleficence, but 89 seemingly also justice, through allocating limited resources to expensive and ineffective treatments.
Moreover, deliberately misleading patients about therapeutic benefits would surely negate 'informed' 91 consent and autonomous decision-making concerning treatment. While psychiatry may sometimes 92 involve errors of clinical judgement, the idea that so many medical practitioners are complicit in 93 breaching fundamental professional ethics seems implausible and devoid of apparent motivation.
94 Claim 2 -minimisation or even denial of severe side effects.

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ECT opponents claim that psychiatry fails to acknowledge the extent, severity, or even existence of 96 severe potential side effects from ECT, including "brain damage", "mortality", and "traumatic impact 97 on the brain" (10). However, as with lack of effectiveness, claims that ECT has such side effects, which 98 are deliberately and collectively concealed, denied, or minimised by psychiatrists, once again implies 99 multiple seemingly implausible and unmotivated ethical violations.

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It is widely acknowledged that ECT's most substantial side effect can be "retrospective 101 autobiographical memory" loss and the substantial research exploring ways to reduce retrograde 102 amnesia indicates, very clearly, that psychiatry is neither ignoring nor denying this issue (1,16,17).

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Historically, this phenomenon was underacknowledged or even denied (16) and some clinicians, as I 104 myself have witnessed, may still fail to attribute sufficient weight to its nature and impact. While 105 guidance materials and clinical decision-making now usually include consideration and information 106 about such side effects, a desire to emphasise potential benefits may lead to insufficient attention being 107 devoted to issues surrounding retrograde amnesia. For example, the new Royal College of Psychiatrists 108 ECT information leaflet mentions the possibility of "permanent" gaps under "Short-term" rather than 109 "Long-term" side effects (18). Assessing memory issues is further complicated by the difficulties of 110 differentiating residual cognitive impairment resulting from depression from the effects of ECT, which 111 can itself help to relieve these impairments (19 fortunate to have support from multiple people who understand and help to fill in the gaps. For myself 118 and many others (3), although not for everyone, benefits of treatment have undoubtedly outweighed 119 these costs. Beyond these autobiographical memory gaps, however, no clinical evidence supports 120 common accusations of permanent 'brain damage', physical damage, or major fatality risk 121 (1,5,9,10,12,22). 122

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A final major concern is the proportion of patients receiving ECT without providing informed consent, 124 usually described by ECT opponents using language implying physical coercion (8

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In almost all countries, ECT now involves general anaesthesia and a muscle relaxant to prevent major 156 physical convulsion (1,3). In the UK, for example, ECT staff are trained to answer any questions or 157 concerns, provide calming environments both pre-and post-treatment, and conduct physical and 158 cognitive checks (28). For me, when severely unwell, my fears concerning ECT stem entirely from 159 persecutory delusions about "brain-control", rather than fear of the physical process itself. Most 160 importantly, perhaps, ECT opponents rarely describe the realities of conditions treated by ECT, 161 Unfortunately, terminology used to defend ECT, such as 'debilitating', 'depression', or even 'life-162 threatening', barely evokes the experience of severe affective disorders or their potential consequences.

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Though hard to articulate, I offer some personal examples to try to demonstrate the lived experience 164 and dangers of such conditions and reasons for prescribing ECT. When becoming severely unwell, I 165 suddenly enter an internal world utterly detached from everything and everyone around me. The US 166 psychiatrist Jamison's description of her own mixed affective state prior to attempting suicide has 167 always resonated deeply -her mind a "murderous cauldron" her body "uninhabitable", "raging and 168 weeping and full of destruction and wild energy gone amok" (29). For me, "tortuous energy" is 169 underpinned by manic grandiosity and invincibility, with intermittent euphoria pushing me towards 170 enlightenment, but accompanied by terrifying paranoia. This lethal combination is all the more 171 dangerous, usually veiled under a deceptive presentation of calm lucidity. ).

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Based on prejudicial and unjustified assumptions about the intrinsic illegitimacy and immorality of 202 psychiatry, many anti-ECT academics simply assume a lack of credibility in the evidence and 203 testimonies presented by psychiatrists. Similar assumptions about intrinsic vulnerabilities or credulity 204 lead to dismissal or even discrimination against ECT advocates who, like myself, claim to have 205 benefited from the treatment. As Dukakis writes in a thoughtful collection of testimonies from those 206 who have benefited from ECT, including her own: "I fully expect to be attacked. I feel like I am putting 207 a target on my back for ECT's many critics" (3). Moreover, the views and utter intransigence of calls 208 for suspension or abolition of ECT take no account of potential harms from depriving those helped by 209 ECT treatment and deterring those who are severely unwell from considering treatment which could 210 help to relieve their suffering.

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Public perceptions of ECT may well still be dominated by a One Flew Over the Cuckoo's Nest image. 212 Currently, the sensationalist and flawed views of the academic anti-ECT lobby continue to bolster such 213 damaging and unjustified public perceptions and media discussion, rendering it unlikely that any 214 supporting evidence for ECT will ever receive balanced consideration. No matter how much evidence 215 is presented in journals, unless psychiatry is proactive in educating people about ECT and is helped, 216 rather than hindered, by the media, ECT's 'image problem' will persist. The stigma surrounding ECT 217 means "that its use is severely limited, and its merits are neglected or even denied" (11), with even those 218 psychiatrists who recognise its effectiveness deterred from prescribing ECT and training others (3).

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My arguments are in no way intended to deny any historic or even contemporary instances of misuse 220 (11), or to negate the views of service users who have experienced harm from ECT, either without any 221 benefits, or with benefits which cannot outweigh the damage. However, any rights-based approach must 222 surely recognise the rights of individuals to conduct their own cost-benefit analysis and to have available 223 to them a treatment with the potential to alleviate severely debilitating and dangerous symptoms (3,11).

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From a personal perspective, ECT does not cure bipolar disorder and the condition is for me, as for so 225 many others, an ongoing challenge. I am incredibly lucky to have levels of social, clinical, and material 226 support unavailable to many. I am aware of the high probability that I may one day become severely 227 unwell again. I am also aware that, if I do, I will need ECT and, when I receive the first treatments, there may well be some element of coercion, whether formal or informal. Almost certainly, I will 229 experience some degree of memory loss. But today I am alive. I have two happy and healthy daughters 230 and am able to perform a job which is both deeply stimulating and rewarding. Only a few years ago 231 many, if not all, of these things would have seemed highly improbable. Without ECT, it is almost certain 232 that they would not have happened.